Nursing Process Flashcards

A client reports pain of 8/10 and is grimacing while guarding the abdomen. Which statement correctly classifies this data?

Answer: The pain rating is subjective data and the grimacing and guarding are objective data

Subjective data is what the client reports, and objective data is what the nurse observes or measures.

Which nursing diagnosis is written in the correct problem-etiology-signs/symptoms (PES) format?

Answer: Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO2 of 86% and restlessness

A PES statement names a nursing problem, a cause the nurse can address, and the defining characteristics that support it.

A postoperative client's outcome reads: 'Client will ambulate better.' What is the main flaw in this outcome?

Answer: It is not measurable and has no time frame

Outcomes must be specific, measurable, achievable, realistic, and time-bound, such as 'will ambulate 50 feet with a walker by postoperative day 2.'

While the nurse is giving a scheduled bed bath, the client suddenly becomes short of breath and anxious. What should the nurse do first?

Answer: Stop the bath and assess the client's respiratory status and oxygen saturation

A change in condition calls for reassessment before any other action, because assessment comes first in the nursing process.

Which client goal is an example of a long-term goal?

Answer: The client will maintain HbA1c below 7% over the next 6 months

Long-term goals are reached over weeks to months and often continue after discharge.

The nurse independently repositions a client every 2 hours to prevent pressure injury. Which type of intervention is this?

Answer: Independent intervention

Independent interventions are actions nurses may start on their own authority without a provider's order.

A client's goal was to drink 2,000 mL of fluid per day, but the intake record shows 900 mL. What is the nurse's best next step?

Answer: Reassess the client to find barriers to fluid intake and revise the plan

When a goal is unmet, the nurse reassesses for causes and revises the diagnosis, goals, or interventions.